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IFOR CITY VALIDATION <br /> <br />]Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTYDswLoBUILDINGca,,rr~INSPECTION ! FOR CITY~USE_ONLY~ ] <br /> co 2~s c~mm'i:'r~:: s:. ~~ii~i~ ~ r~ ~ ,--: ~.l~ty ~ m,:~.: / <br /> <br /> Salem, Orego . <br /> <br /> 24hr'Ins~..L~:~.'.~..I~.J~7~04 ~l ~l~l$ide'~ ~ ~/: Im~tside: ~,_~'I <br /> IP~2_4_ <br /> BU~D~G PE~ APP~m <br /> ~0~ ~0~ <br /> <br /> RESIDENTIAL COMMERCIAL <br /> <br />( ) Addition ( ) Relocation ( ) Addition <br />( ) Alteration ( ) Other ( ) Alteration <br />( b~ccessory ( ) Change of Occupancy <br />~sc~ipion of work <br /> <br />) New <br /> <br />) Sign <br /> <br />) Other <br /> <br />New - <br /> <br />Use of Structure: <br /> <br />I Is fids a historical building? Yes - No <br /> INo. Bedrooms: <br /> <br />2. LOCATION OF INSTALLATION <br />lob Address ~~ <br /> <br />Mobile Hom~ Park <br /> <br />~ s.m ,5-,~ <br /> <br />Block <br /> <br />Wa~r Supply: <br />Private Well ( ) Spring ( ) <br />Community Well ( ) City ( ) <br /> <br />3. CoI~rRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />am the PROPERTY OWNER and own, reside in, or will reside in the completed slmcture and will be my own general conlractor. I understand that I must regisler as a construction <br />conm~mr if the sUucture is sold or offered for sale before or upon completion. If I hire subcontractors, I will hire only subcontractors ~e~istered with the Construction Contractors Board. <br />If I clumge my mind and do hire a general comractor who is registered with the Construction ConWactors Board, I will immediately not~ ~M~ion County of the name of the conU~cto ~r~x <br />· R:~tr~on.o. ; (~ ~'-k'-~ / <br />am an AUTHORIZED RF_~RF~ENTATIVE of theXl/wperty owner or contractor. <br />Name <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project) Vnluation: $ <br />( 1 ) Permit Fee <br />(2) 5% State Surcharge (.05 x Al) = <br />(3) Suuctural Plnn Review (.65% x Al) = <br />(4) ~h,:: & :_.ii:, Y,~: l"~ X~,L, (.~%'~'Y.. x A:) % .~..a..~ = <br />(.5) Zoning Surcharge., if applicable (.05% x A 1 ) = <br />(6) Seismic Surehnrge = <br /> <br />5=-0. <br /> <br />B. ~scetU~ous~ees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspoction Fee O $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />~ .~.on-~,r~a~= ~.p~ i~ wo~ i, no,,~ wi~ ~S0 dm o~i..~c=~r i~ wo~* i~ ,u~n~e for ~S0 ~y,. C--.~'-~ q-- <br />Name of Applicant (Please PlinO: ~/~f~__,.~'~ ff~. Z[~-.-~' ~t~ / Phone:7/~2'''-0 ~'--"' .~(~)ZO / -- <br />Signature of Applicant ~~~'~~ ~'" ~ ~- <br /> <br /> Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />